Documentation

[HERBIE1]

Just curious Herbie, we have the Zoll "Rescue Net" programme for our ePCR's. While obviously not the best programme on the market, the number one thing I like about it is the ability to write my own narrative. I was just wondering if the programme you use has that feature or is it a computer generated narrative.

To the OP, I use the CHART method of writing a narrative. I just find it more comfortable for me. Which ever method you choose to use is fine as long as all pertinent information is included in it. Good advice from the other forum members!

Ours was adapted from "Safety Pad", but like vehicle specs, those who are tasked with doing it are not the ones who use it in the field. It does not autogenerate a narrative, but after clicking on all the required fields, the information is present in the report, although you need to hunt for it. You do have the option of putting a narrative in each section- physical exam, vitals, treatment, etc, I choose to write one integrated summary that covers the entire call. It's more fluid, it tells the entire story and paints the proper picture of what happened with that patient. The specifics and details like times, dosages, etc are included elsewhere in the report, under their respective headings.

When appropriate, I repeat the treatments in my comments when for example, the patient improves or decompensates after an intervention because the program does not allow for that type of documentation.

I understand the benefit of using an e-report- quicker billing, easier tracking of data, QA and QI purposes, etc, but certain things simply cannot be adequately expressed via a software aided program.

[JakeEMTP]

I understand the benefit of using an e-report- quicker billing, easier tracking of data, QA and QI purposes, etc, but certain things simply cannot be adequately expressed via a software aided program.

Agreed. There is no substitute for a written narrative. Auto-generated narratives cannot possibly descibe the scene, the way the pt. presented, how they responded to treatment etc.

[PennCareInc]

EMSCharts is a solid ePCR system... In the billing and claims department I might also suggest AdvanceClaim (hosted offsite, has an online graphical user interface, redundantly stores data, etc).